Wasting is a persistent public health problem affecting 45 million children under five years of age worldwide. Wasting is responsible for the deaths of 875,000 children under the age of five every year. Children who survive often suffer from long-term cognitive and physical disabilities UNICEF, the World Health Organization, and the World Bank 2021; Black et al. 2013). Member countries of the World Health Assembly (WHA) have agreed to reduce and maintain the prevalence of wasting to less than 5 percent by 2025. Most Sahelian countries are off track to meet the WHA targets and in Chad, the prevalence of wasting is still unacceptably high at 14 percent and shows large regional disparities (UNICEF, the World Health Organization, and the World Bank 2020). While both wasting prevention and treatment programs hold the potential to reduce child wasting, substantial synergies can be expected when prevention is integrated with screening, referral, and treatment services. Such integration should happen at the community level to maximize the accessibility of services for caregivers and their children.

• Family-led MUAC, where caregivers and other household members screen their own children regularly to detect child wasting early-on, is a promising strategy to boost screening coverage leading to more children with wasting to be referred and enrolled in available treatment services. • In settings with regular active screening for wasting by community care groups in Chad and Mali, family-led MUAC had limited reach and effectiveness, thus contributing few additional cases detected, referred, and enrolled in wasting treatment services. • The introduction of family-led MUAC remained below expectation because the anticipated monthly home visits (main delivery platform) represented too much of a workload for volunteers. Monthly group sessions can be a suitable platform to train households to apply family-led MUAC on the condition that the attending number of caregivers per session is capped to allow for a more individualized approach. • Less than half of the households disposing of MUAC tapes screened their children monthly. The main reason reported for non-adoption was lack of knowledge and confidence on how to conduct the measurements, which calls for better training of caregivers and more social support to conduct the measurements. • Both the inadequate introduction by community volunteers, as well as the poor adoption by households of family-led MUAC resulted in a low reach of monthly screening by households (up to 10% in Chad and up to 25% in Mali). • Caregivers were able to measure their children’s MUAC accurately, and caregiver knowledge of family-led MUAC was moderate (Mali) to very high (Chad). • The short duration of the IRAM program (7-9 months), due to the COVID-19 crisis, may have hampered a continuous learning process leading to improvement of family-led MUAC over time.

The use of theories, models and evaluation frameworks to design and evaluate interventions has now taken center stage in implementation science. The RE-AIM framework is one of the most used frameworks to plan and evaluate the implementation of interventions. RE-AIM framework is not only useful for researchers but also allows program implementers to broaden and structure their analysis to strengthen program implementation, design a performant monitoring and evaluation framework or conduct implementation research. The framework’s key dimensions are reach and effectiveness (at an individual level), adoption and implementation (at actor, staff, system, or policy/other levels), and maintenance (both at individual and actor/staff/system/policy levels) (Box 1). The utilization of the RE-AIM framework is not limited to assessing if a program reaches satisfactory levels of each dimension, but also aims at understanding the barriers and facilitating factors of each dimension. Furthermore, it recommends identifying which subgroups of actors or settings demonstrate good or poor adoption and implementation and to assess which subgroups of program beneficiaries benefit most from good intervention reach and effectiveness. Whereas most experience with RE-AIM comes from public health and behavioral studies conducted in high-income countries, the framework has been increasingly used for programs and interventions implemented in low-and middle-income countries and in a variety of thematic fields. Furthermore, the framework has been extensively used to assess the implementation of interventions consisting of few components. For the assessment of multi-component interventions, one way of applying RE-AIM to is first decompose the multi-components intervention into single components or activities and evaluate every component separately. However, such complex interventions can consist of intervention components or services that are either sequenced, layered, or integrated which may require an extension of the existing RE-AIM framework to evaluate the interaction between intervention components or services. This technical brief provides an example on how RE-AIM was operationalized by the Integrated Research on Acute Malnutrition (IRAM) which assessed the implementation and impact of a complex intervention package. The IRAM intervention aimed at strengthening various services along the continuum of care of child wasting in Mali. IRAM defined the continuum of care of child wasting as a series of services offered by different providers at various levels of care (household, community, facility) that cover the prevention of wasting, the screening for wasting, the referral of cases to treatment services, the admission and treatment of cases, and the post-treatment follow-up and prevention of relapse. We first show how REAIM was applied on single IRAM intervention components and services. We then highlight a few limitations that we encountered with RE-AIM for a complex intervention package and propose how to extend RE-AIM for interventions or services that are sequenced, layered, or integrated.

Wasting is a persistent public health problem affecting 45.4 million children under five years of age worldwide. Wasting is responsible for the deaths of 875,000 children under the age of five every year. Children who survive often suffer long-term damage to their cognitive and physical development. Member countries of the World Health Assembly (WHA) have agreed to reduce and maintain the prevalence of wasting to less than 5 percent by 2025. Despite the commitment to tackle wasting, however, only one country in West Africa is on course to meet the WHA target. In contrast, seven countries, including Mali, have made no progress or have a worsening situation. In Mali, estimates from 2020 show prevalence levels of 9.3 percent, with critical regional disparities. Existing programs that aim to prevent or treat child wasting exist but typically suffer from low coverage and tend to be poorly integrated. While both strengthened prevention and treatment of wasting hold the potential to impact child wasting, substantial synergies can be expected when prevention is integrated with screening, referral, and treatment services. Such integration should happen at the community level to maximize the accessibility of services for caregivers and their children. Since the introduction of Mali's national infant and young child feeding strategy in 2012 (Ministère de la Santé du Mali 2012), community care groups called Nutrition Action Support Groups (NASGs) have taken center stage in delivering preventive behavior change communication (BCC) on infant and young child feeding (IYCF) practices and child health. However, to leverage the impact of these efforts on child wasting, NASG services need to be extended to support existing community-based treatment services and to prevent any posttreatment relapse. Further evidence is needed on the coverage and quality of implementation of these community groups, as existing evidence is scarce.